PERSONAL INFORMATION
EDUCATIONAL BACKGROUND
Unstable angina
MI ACS
Ischemic stroke/TIA
Critical leg ischemia
Intermittent
Atherosclerosis claudication
CV death
14
Cardiovascular Disease
• Acute Myocardial Infarction (Heart Attack) - leading
cause of death in U.S.
Asymptomatic Symptomatic
ACS
Working Dx
NSTE-ACS
24
THE ELECTROCARDIOGRAM
• 12 lead EKG
• Cornerstone of initial evaluation
• Within 10 minutes of presentation
• Previous EKG tracings
• Compare
• Serial EKGs
• Essential
THE ELECTROCARDIOGRAM
1. ST segment elevation 2mm (2 contiguous leads), new LBBB, true posterior
ischemia
STEMI
Manage
medically
Algorithm for Management of Patients With Definite or Likely NSTE-ACS
NSTE-ACS:
Definite or Likely
Initiate DAPT and Anticoagulant Therapy Initiate DAPT and Anticoagulant Therapy
1. ASA (Class I; LOE: A) 1. ASA (Class I; LOE: A)
2. P2Y12 inhibitor (in addition to ASA) (Class I; LOE: B) : 2. P2Y12 inhibitor (in addition to ASA) (Class I; LOE: B):
· Clopidogrel or · Clopidogrel or
· Ticagrelor · Ticagrelor
3. Anticoagulant: 3. Anticoagulant:
· UFH (Class I; LOE: B) or · UFH (Class I; LOE: B) or
· Enoxaparin (Class I; LOE: A) or · Enoxaparin (Class I; LOE: A) or
· Fondaparinux (Class I; LOE: B) · Fondaparinux† (Class I; LOE: B) or
· Bivalirudin (Class I; LOE: B)
Can consider GPI in addition to ASA and P2Y12 inhibitor
in high-risk (e.g., troponin positive) pts
(Class IIb; LOE: B)
· Eptifibatide
· Tirofiban
Medical therapy
chosen based on cath
findings
Therapy Therapy
Effective Ineffective
Therapy Therapy
Effective Ineffective
†Inpatients who have been treated with fondaparinux (as upfront therapy) who are
undergoing PCI, an additional anticoagulant with anti-IIa activity should be administered at
the time of PCI because of the risk of catheter thrombosis.
Early Hospital Care
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
Regional Systems of STEMI Care,
Reperfusion Therapy, and Time-to-Treatment
Goals
I IIa IIb III
All communities should create and maintain a regional system of
STEMI care that includes assessment and continuous quality
improvement of EMS and hospital-based activities. Performance
can be facilitated by participating in programs such as Mission:
Lifeline and the D2B Alliance.
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Regional Systems of STEMI Care,
Reperfusion Therapy, and Time-to-Treatment
Goals
I IIa IIb III
Immediate transfer to a PCI-capable hospital for primary PCI is the
recommended triage strategy for patients with STEMI who initially
arrive at or are transported to a non–PCI-capable hospital, with an
FMC-to-device time system goal of 120 minutes or less.*
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Regional Systems of STEMI Care,
Reperfusion Therapy, and Time-to-Treatment
Goals
*The proposed time windows are system goals. For any individual patient, every effort should be
made to provide reperfusion therapy as rapidly as possible.
Reperfusion at a PCI-Capable Hospital
Beta Blockers
Beta Blockers
I IIa IIb III
Oral beta blockers should be initiated in the first 24 hours in
patients with STEMI who do not have any of the following: signs
of HF, evidence of a low output state, increased risk for
cardiogenic shock,* or other contraindications to use of oral beta
blockers (PR interval >0.24 seconds, second- or third-degree
heart block, active asthma, or reactive airways disease).
I IIa IIb III
Beta blockers should be continued during and after
hospitalization for all patients with STEMI and with no
contraindications to their use.
*Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the
risk of developing cardiogenic shock) are age >70 years, systolic BP <120 mm Hg, sinus
tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of
STEMI.
Beta Blockers
Renin-Angiotensin-
Aldosterone System
Inhibitors
Renin-Angiotensin-Aldosterone System
Inhibitors
I IIa IIb III
An ACE inhibitor should be administered within the first 24 hours
to all patients with STEMI with anterior location, HF, or EF less
than or equal to 0.40, unless contraindicated.
Lipid Management
Lipid Management